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Prehospital Care of Severely Injured Trauma Patients: Studies on Management, Assessment, and Outcome

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Prehospital Care of Severely Injured Trauma Patients: Studies on Management, Assessment, and Outcome From the DEPARTMENT OF CLINICAL SCIENCE AND EDUCATION, SÖDERSJUKHUSET Karolinska Institutet, Stockholm, Sweden PREHOSPITAL CARE OF SEVERELY INJURED TRAUMA PATIENTS: STUDIES ON MANAGEMENT, ASSESSMENT, AND OUTCOME Rebecka Rubenson Wahlin Stockholm 2016 All previously published papers were reproduced with the permission of the publisher. Cover photo © Johan Larsson Published by Karolinska Institutet. Printed by Eprint AB 2016 © Rebecka Rubenson Wahlin, 2016 ISBN 978-91-7676-481-7 Prehospital Care of Severely Injured Trauma Patients: Studies on Management, Assessment and Outcome THESIS FOR DOCTORAL DEGREE (Ph.D.) By Rebecka Rubenson Wahlin Principal Supervisor: Opponent: Professor Sari Ponzer Associate Professor Lovisa Strömmer Karolinska Institutet Karolinska Institutet Department of Clinical Science and Education, Department of Clinical Science, Intervention, Södersjukhuset and Technology Co-supervisor(s): Examination Board: Professor Maaret Castrén Associate Professor Marie Hasselberg University of Helsinki, Finland Karolinska Institutet Department of Emergency Medicine and Services Department of Public Health Sciences and Karolinska Institutet Department of Clinical Science and Education, Associate Professor Lennart Boström Södersjukhuset Karolinska Institutet Department of Clinical Science and Education Professor Hans Morten Lossius Södersjukhuset University of Stavanger, Norway Field of Prehospital Critical Care, Network for Professor Björn-Ove Suserud Medical Sciences University of Borås and Karolinska Institutet Faculty of Caring Science, Working Life and Department of Clinical Science and Education, Social Welfare Södersjukhuset Dr. Markus B Skrifvars University of Helsinki, Finland Department of Anesthesiology, Intensive Care and Pain Medicine, Division of Intensive Care Medicine “För att de utsatta skall vara de utvalda" To Hasse, Noah, Joel, and Adam ABSTRACT Trauma is a public health issue. According to statistics from the Swedish National Board of Health and Welfare, circumstances related to injury are the most common cause of death in the age group 15– 44 years for both genders. Prehospital care is the first link in the chain of life support. Trauma systems and regionalized trauma care have been shown to improve outcome in severely injured trauma patients, but less is known about whether gender influences the prehospital trauma care. Management in the prehospital phase of traumatic brain injury (TBI) is focused on limiting the effects of secondary insults, such as hypoxia and hypotension, and advanced prehospital airway management might potentially improve the outcome. The overall aim of this thesis was to evaluate the prehospital assessment, management and outcome in severely injured trauma patients within a regional trauma system. Paper I. A retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County. 693 primarily admitted trauma patients were included for the years 2006 and 2008. For the years 2006, 2008, and 2013, there were 114 secondarily transported trauma patients. The number of primary patient transports to the trauma center increased during these years by 20.2%, (p <0.001). Primarily transported patients had a significantly higher Injury Severity Score (ISS) in 2008 than in 2006, and the number of patients transported secondarily to the trauma center in 2006 was higher compared to 2008 and 2013 (p<0.001). Paper II. A retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County. A total of 383 trauma patients (279 males and 104 females) >15 years of age with an ISS of >15 transported to emergency care hospitals in the Stockholm area were included. Male patients had a 2.75 higher odds ratio (95% CI, 1.2–6.2) for receiving the highest prehospital priority compared to females on controlling for injury mechanism and vital signs on scene. Paper III. A retrospective observational study based on 2750 prehospital medical records of suspected TBI patients. 25.2 % of the patients were assessed according to all four core-elements in the guidelines and 78.6% of the patients underwent at least one intervention by the PECNs. Male patients were to a higher extent assessed according to guidelines and were given higher transport priority while females were more often assessed for vital parameters and received significantly more analgesics. Paper IV. A retrospective observational study based on 459 TBI patients ≥15 years admitted to the neurosurgical unit in Stockholm between the years 2008 and 2014. High energy trauma, prehospital hypotension, pupil unresponsiveness, mode of transportation and distance to the hospital were independently related to an increased rate of pre-hospital intubation (model explained p<0.001, pseudo-R2 0.482). Pre-hospital intubation did not correlate to outcome of the unconscious patients (p=0.296), or add independent information to the model of significant parameters in multivariate analysis vs. GOS (p=0.154). Transports >10 km had an intubation frequency of about 50%. With the introduction of a prehospital trauma transport directive, an increase in patients transported to the regional trauma center and a decrease in secondary transfers were detected, but a considerable number of severely injured patients were still transported to local hospitals. The results also indicated that prehospital prioritization among the severely injured and the assessment and management of parameters related to head trauma differed between genders. Pre-hospital intubation could not be related to outcome. Large multicenter prospective studies with structured protocols are of importance in order to determine potentially beneficial effects of prehospital advanced airway management. LIST OF SCIENTIFIC PAPERS I. Effect of an organizational change in a prehospital trauma care protocol and trauma transport directive in a large urban city: a before and after study. Rubenson Wahlin R, Ponzer S, Skrifvars M, Lossius HM, Castrén M. Scand J Trauma Resusc Emerg Med. 2016 Mar 9;24:26. II. Do male and female trauma patients receive the same prehospital care?: an observational follow-up study. Rubenson Wahlin R, Ponzer S, Lövbrand H, Skrivfars M, Lossius HM, Castrén M. BMC Emerg Med. 2016 Jan 19;16:6 III. Patients with head trauma: a study on initial prehospital assessment and care. Rubenson Wahlin R, Lindström V, Ponzer S, Vicente V Submitted IV. Prehospital advanced airway management of patients with traumatic brain injury; relations to outcome in a Swedish trauma cohort Rebecka Rubenson Wahlin, David Nelson, Bo-Michael Bellander, Mikael Svensson and Eric Peter Thelin. Manuscript CONTENTS 1 Introduction.................................................................................................................. 1 1.1 Epidemiology of trauma and traumatic brain injury ......................................... 1 1.2 Prehospital Trauma Care .................................................................................... 2 1.2.1 Prehospital trauma care and ABCDE principles .................................... 3 1.2.2 Airway (with cervical stabilization) and breathing ................................ 3 1.2.3 Circulation and hemorrhage control ...................................................... 4 1.2.4 Disability ............................................................................................... 5 1.2.5 Exposure ................................................................................................ 5 1.2.6 Analgesics ............................................................................................. 6 1.3 Prehospital care of patients with Traumatic Brain Injury ................................... 6 1.3.1 Primary Injury ....................................................................................... 6 1.3.2 Secondary Injury ................................................................................... 7 1.3.3 Prehospital management of TBI ............................................................ 7 1.4 Trauma systems ................................................................................................. 7 1.4.1 Types of trauma systems ....................................................................... 9 1.4.2 Trauma systems worldwide ................................................................. 10 1.4.3 North America and Australia ............................................................... 11 1.4.4 Europe ................................................................................................. 12 1.4.5 Nordic countries .................................................................................. 13 1.4.6 Sweden ................................................................................................ 14 1.5 Trauma registries ............................................................................................. 14 1.6 Trauma scores .................................................................................................. 15 1.6.1 Abbreviated Injury Scale ..................................................................... 15 1.6.2 Injury Severity Score ........................................................................... 15 1.6.3 Glasgow Coma Scale ........................................................................... 15 1.6.4 Revised Trauma Score ......................................................................... 16 1.6.5 National Advisory Committee for Aeronautics (NACA) ....................
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